Latest / Vanguards of Healthcare by Bloomberg Intelligence / Cityblock Health Reimagines Care for Those Left Behind

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Cityblock Health Reimagines Care for Those Left Behind · Vanguards of Healthcare by Bloomberg Intelligence

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  Speaker 1: Welcome to another episode of Bloomberg Intelligence's Vanguards of Healthcare podcast,
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  Speaker 1: where we speak with the leaders at the forefront of
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  Speaker 1: change in the healthcare industry. My name is Jonathan Palmer,
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  Speaker 1: and I'm a healthcare analyst at Bloomberg Intelligence, the in-house
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  Speaker 1: research arm of Bloomberg. We're very excited to have Dr.
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  Speaker 1: Talian Ajayi CEO and co-founder of CityBlock Health, joining us today.
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  Speaker 1: She's a family physician by training and previously served as
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  Speaker 1: chief medical officer of the Commonwealth Care Alliance before co-founding
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  Speaker 1: CityBlock in 2017. The company has built a value-based healthcare
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  Speaker 1: model focused on some of the most complex populations in
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  Speaker 1: the industry, particularly Medicaid and dual eligible members combining medical, behavioral,
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  Speaker 1: and social care. There's so much to unpack around CityBlock's model,
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  Speaker 1: its growth, and where the company goes from here. Talia,
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  Speaker 1: welcome to the podcast.
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  Speaker 2: Thank you so much. I'm delighted to be here.
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  Speaker 1: So for our listeners who may not know CityBlock, how
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  Speaker 1: would you describe its mission, the populations it serves, and
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  Speaker 1: what role you play in the healthcare ecosystem?
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  Speaker 2: Amazing. Well, our mission is really to transform care outcomes
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  Speaker 2: for people who get left behind by the healthcare system.
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  Speaker 2: So the folks are the most vulnerable to all of
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  Speaker 2: the ways in which our healthcare system falls apart, especially
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  Speaker 2: when you need lots and lots of support and services.
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  Speaker 2: We focus on people with complex healthcare needs and people
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  Speaker 2: who are hard to reach. be they urban or rural,
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  Speaker 2: be they on Medicaid or Medicare or a combination of
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  Speaker 2: the two. And I think the thing that's most sort
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  Speaker 2: of distinctive about us is that we've aligned our business
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  Speaker 2: model so that our incentives are actually pushing us towards
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  Speaker 2: improving outcomes, but also managing the cost of those outcomes,
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  Speaker 2: which I believe, and I'm sure you probably agree, is
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  Speaker 2: like the existential problem facing our healthcare system is like
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  Speaker 2: we cannot continue to manage costs as we have in
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  Speaker 2: the past. We have to align outcomes around patient experience,
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  Speaker 2: their satisfaction, quality, and cost and affordability.
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  Speaker 1: So where did the idea come for you and your
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  Speaker 1: co-founders to actually start the company? Where was the light
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  Speaker 1: bulb moment?
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  Speaker 2: I think everybody has, you know, you converge on the
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  Speaker 2: same idea from different perspectives. So I can speak only
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  Speaker 2: to really mine, which was, you know, I started my
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  Speaker 2: career as a physician practicing in safety net hospitals and
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  Speaker 2: community health centers and really believed that being a doctor
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  Speaker 2: and taking care of patients, particularly people with complex needs
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  Speaker 2: and low income, would give me the fulfillment that I
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  Speaker 2: was seeking and also allow me to be part of
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  Speaker 2: a positive change in the world and really to help people.
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  Speaker 2: And pretty quickly, I figured out that this was not
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  Speaker 2: going to be the path. I felt like I was
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  Speaker 2: just a revolving door. I felt like I was patching
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  Speaker 2: people up when things were really bad and putting a
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  Speaker 2: tiny bandaid on what were gaping wounds and sending them
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  Speaker 2: back out into the same circumstances that brought them in
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  Speaker 2: in the first place, both on the hospital side and
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  Speaker 2: when I was in clinic in a community health center,
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  Speaker 2: because You know, doctors there typically are seeing patients on
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  Speaker 2: a fee-for-service basis, which means you need to see as
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  Speaker 2: many folks as you can before the day is up.
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  Speaker 2: You don't have the time necessary to spend doing a
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  Speaker 2: home visit, really understanding the complexity of what's going on
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  Speaker 2: with someone coordinating with all of their different providers, talking
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  Speaker 2: to their daughter or their granddaughter who's doing all the
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  Speaker 2: care at home, figuring out if they really actually do
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  Speaker 2: understand the instructions or they're just saying so because they
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  Speaker 2: really want to make you feel better. Those types of
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  Speaker 2: things were– I knew they were missing sometimes. But I
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  Speaker 2: just couldn't figure out how in the existing system to
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  Speaker 2: actually address those issues. And so the motivation for CityBlock
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  Speaker 2: was to say, I think we need to redesign the system.
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  Speaker 2: I actually don't think it's that the doctors are not well-meaning,
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  Speaker 2: that the nurses are not well-meaning, that these institutions don't
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  Speaker 2: mean well. It's that our structures do not enable us
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  Speaker 2: to deliver the kind of care that's actually going to
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  Speaker 2: holistically meet people's needs and drive better outcomes and definitionally
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  Speaker 2: be better cost, lower cost for us because we're doing
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  Speaker 2: the things that are upstream. And so that was the
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  Speaker 2: sort of inspiration and the motivation for building this business.
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  Speaker 1: And then with that thesis in mind, what did you
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  Speaker 1: go about to build first? Can you walk me through
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  Speaker 1: the progression of how the company actually got established?
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  Speaker 2: Yeah. So we were very fortunate to be incubated at
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  Speaker 2: Sidewalk Labs, which is a really... unique and wonderful experience
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  Speaker 2: for a startup because you have some institutional funding, you
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  Speaker 2: have a startup capital, you have technology that you can
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  Speaker 2: pull in. I mean, it was part of the alphabet family.
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  Speaker 2: So you can imagine the talent that we're able to
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  Speaker 2: pull in. It's not a typical founding story for a startup,
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  Speaker 2: but it was really amazing for us to have that.
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  Speaker 2: And we started to build the basic ingredients of what
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  Speaker 2: we thought this business needed to become. And the first
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  Speaker 2: thing that I believed was that we needed to figure
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  Speaker 2: out how to engage people. So when you think about
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  Speaker 2: a population of folks, 10,000 people, if you can identify
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  Speaker 2: in the data, typically, who's going to need health care more?
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  Speaker 2: And you look at folks who've got multiple chronic conditions,
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  Speaker 2: people who might have a mental health diagnosis, someone who
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  Speaker 2: was admitted for an opioid overdose. Those types of folks
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  Speaker 2: show up in the data as having really high needs.
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  Speaker 2: When you look across how they use health care, often
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  Speaker 2: they're not getting the right amount of primary care and
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  Speaker 2: mental health in the community. So when you look at
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  Speaker 2: their overall health care claims, what you tend to see
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  Speaker 2: is a lot of hospitalizations, a lot of time in
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  Speaker 2: the nursing home, a lot of time maybe in specialist care,
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  Speaker 2: disproportionately too little time in primary care offices and in
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  Speaker 2: primary behavioral health. And so you know there's something there, right?
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  Speaker 2: Like there's a mismatch between what's happening. And you can
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  Speaker 2: sort of see it play out in clinical stories. You
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  Speaker 2: can imagine somebody with anxiety and depression and COPD, so
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  Speaker 2: breathing difficulties, who is having a hard time keeping a
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  Speaker 2: roof over their head and food in their belly and
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  Speaker 2: maybe doesn't go to see their primary care doctor, doesn't
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  Speaker 2: see their pulmonologist, hasn't really addressed their anxiety and depression.
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  Speaker 2: But every time it's a flu season, they come into
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  Speaker 2: the hospital super sick and they end up in the ICU.
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  Speaker 2: And every time they get exposed to a virus from
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  Speaker 2: their grandchild at daycare, they get super sick and end
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  Speaker 2: up in the ICU. And so you see these spikes
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  Speaker 2: that are really costing. You think, gosh, if I could
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  Speaker 2: get this person before they get ill, if I could
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  Speaker 2: get this person on the right medication regimen, if I
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  Speaker 2: could get this person before they've had five, six, seven
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  Speaker 2: days of fever and shortness of breath and calling 911,
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  Speaker 2: I could prevent all of that. I could keep them
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  Speaker 2: in the home. I could keep them healthy. And I
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  Speaker 2: could reduce all the spend in the system. The problem is,
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  Speaker 2: where are they? Right. And how excited are they typically
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  Speaker 2: to pick up the phone when they get a phone
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  Speaker 2: call from their health insurance or their doctor's office, knowing
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  Speaker 2: that to go see their primary care doctor typically is
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  Speaker 2: a four, five, six, seven day wait. They got to
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  Speaker 2: take time off work. They got to do transportation. They're
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  Speaker 2: going to wait in the waiting room with a whole
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  Speaker 2: bunch of other sick people. They're going to get 10
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  Speaker 2: minutes of a doctor's time. It may not feel particularly
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  Speaker 2: good to them. They may get a referral, but it actually,
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  Speaker 2: you know, the therapist isn't available for another six weeks
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  Speaker 2: or the insurance company denies the referral. There's just all
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  Speaker 2: this friction that they know they're gearing up for. So
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  Speaker 2: people aren't super eager to do that. Also, they're busy
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  Speaker 2: living their lives. And for many of them, the cognitive
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  Speaker 2: burden of just managing the day-to-day is so high if
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  Speaker 2: you're trying to just make ends meet. Their health care
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  Speaker 2: falls to the wayside. Falls to the wayside, understandably. These
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  Speaker 2: are not folks who don't want to be healthy. They're
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  Speaker 2: just rational people making choices. in very tight spaces. And
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  Speaker 2: so we figured that the first and most important thing
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  Speaker 2: we had to do is figure out how to engage
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  Speaker 2: these folks. So find them physically and convince them that
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  Speaker 2: we care about them enough that they might give us
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  Speaker 2: their time, which is their most precious asset, share what's
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  Speaker 2: going on with them, including things you wouldn't typically talk
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  Speaker 2: to your doctor about. You know, I'm lonesome. I'm still
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  Speaker 2: smoking cigarettes and I didn't tell anybody. I am occasionally
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  Speaker 2: using illicit substances because I can't get to sleep. And
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  Speaker 2: I'm worried that that's what's causing my anxiety to get worse.
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  Speaker 2: I don't have enough food to eat. And so I'm
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  Speaker 2: skimping on my meds because I can't afford to either
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  Speaker 2: pay the copay or buy food. Those are the types
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  Speaker 2: of things that are so important that often drive a
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  Speaker 2: lot of healthcare spend, but that's invisible to a lot
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  Speaker 2: of the healthcare system because we haven't earned the right
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  Speaker 2: to get that information from people. And then we get it,
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  Speaker 2: we don't know what to do with it. If you
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  Speaker 2: told your doctor- gosh, you know, I'm hungry and I'm
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  Speaker 2: just not sure. They would put it in a note
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  Speaker 2: and it might disappear. No one would ever know. And
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  Speaker 2: it certainly wouldn't drive new behaviors in most traditional healthcare systems,
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  Speaker 2: but that's what we were trying to do. So we
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  Speaker 2: focused on engagement first and built an engagement engine, which is,
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  Speaker 2: it's a lot of humans building trusted relationships with other humans,
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  Speaker 2: but we learned that we can make those relationships stickier
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  Speaker 2: and more powerful and more potent and and more fulfilling
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  Speaker 2: mutually if we informed them with science. And so we
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  Speaker 2: A-B tested and we piloted and we figured out ways
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  Speaker 2: to use technology to enhance that relationship. We figured out
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  Speaker 2: what type of messaging we needed in order to enhance
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  Speaker 2: that relationship. We got really good at finding people who
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  Speaker 2: often had not been found in the sort of traditional
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  Speaker 2: primary care sense of the word, engaging them, and then
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  Speaker 2: convincing them to share things with us that help us
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  Speaker 2: better meet their needs. So we can provide primary care
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  Speaker 2: and mental health and social services to them and keep
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  Speaker 2: them out of the hospital. That was the most important
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  Speaker 2: sort of anchoring step of the business we built. Interestingly,
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  Speaker 2: I think many startups struggle with finding product market fit
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  Speaker 2: or customers or revenue. But, you know, when the thing
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  Speaker 2: you are selling is like better health care at a
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  Speaker 2: lower cost, not surprisingly, there are a lot of customers.
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  Speaker 2: And so we've not struggled yet. historically, to find people
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  Speaker 2: willing to buy what we're selling. But we've just struggled
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  Speaker 2: as every healthcare innovator to totally re-architect the system because
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  Speaker 2: it was built for one purpose, which is to see
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  Speaker 2: as many people as possible. people as quickly as possible
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  Speaker 2: and rebuild as much as possible for doing those things.
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  Speaker 2: And now we're trying to build something that's actually going
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  Speaker 2: to drive outcomes.
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  Speaker 1: Well, I'm so fascinated by the example you gave around
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  Speaker 1: the care team, finding members and engaging with them. Can
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  Speaker 1: you walk us through maybe like what the first 30
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  Speaker 1: days for somebody coming onto CityBlock looks like?
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  Speaker 2: Yeah. Yeah. Um, uniquely they didn't make a selection, right?
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  Speaker 2: Like they, they are, um, the member has a health
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  Speaker 2: insurance company. They pay their claims. They think of their
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  Speaker 2: health insurance. Like they think of any health insurance company. So,
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  Speaker 2: you know, at, at best, um, They're ambivalent. And at worst,
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  Speaker 2: they have strong negative feelings, right? That's just sort of
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  Speaker 2: like the data would support the notion that most people
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  Speaker 2: sort of fall somewhere between those two parameters. I think
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  Speaker 2: that might be kind. Probably a little generous. That's generally
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  Speaker 2: how people feel about their health insurer. But their health
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  Speaker 2: insurer partners with us. And we identify these folks. We
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  Speaker 2: identify a person and say, this person could benefit from
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  Speaker 2: these additional services. And it's incumbent on us to find
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  Speaker 2: them and engage them. And so what we would do
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  Speaker 2: is we would outreach to them. They wouldn't have any
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  Speaker 2: idea who we are often. Sometimes we have, and depending
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  Speaker 2: on communities that we're in, we have some more brand recognition.
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  Speaker 2: And so that's increasing as we've grown a business. But
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  Speaker 2: you can imagine they're going about their day and they
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  Speaker 2: may get a postcard from their health insurer with CityBlock
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  Speaker 2: plus their health insurer that says, we're partnering at no
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  Speaker 2: additional cost to you to give you all these supports
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  Speaker 2: to help you stay healthy. So look out for some outreach.
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  Speaker 2: And then we'll outreach to them. It could be email, text, call.
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  Speaker 2: Could be someone knocking on their door. And we explain
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  Speaker 2: who we are. And we, first of all, listen, most importantly,
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  Speaker 2: to what is most important to them. And that is
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  Speaker 2: a really, I think, critical step that we've learned. Again,
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  Speaker 2: it seems obvious, but it's not the way that health
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  Speaker 2: care typically operates. I can tell you from the perspective
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  Speaker 2: of the doctor, when you're sitting in the office with
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  Speaker 2: a patient, you've got a list of things that you
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  Speaker 2: want to get through. You're worried about their diabetes. You're
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  Speaker 2: worried about their hypertension. You're worried about getting their labs
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  Speaker 2: drawn and their mammogram done. The patient might be worried
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  Speaker 2: about all the other things I described, food on the table, transportation,
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  Speaker 2: a concern about their social setting, or a symptom that
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  Speaker 2: actually doesn't rank on the doctor's list, but it's the
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  Speaker 2: most important thing. My big toe really hurts and I
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  Speaker 2: can't walk from here to there and it's going to
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  Speaker 2: jeopardize everything. And we tend to overwhelm the patient with
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  Speaker 2: our agenda because we've got this electronic record. It's screaming
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  Speaker 2: at us. It's flashing lights. You feel like you'd be
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  Speaker 2: a bad doctor if you let this person leave without
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  Speaker 2: the next step. And what we've learned is actually that
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  Speaker 2: turning that noise off for a second and trying to
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  Speaker 2: meet the person really where they are and to genuinely
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  Speaker 2: listen to what matters to them and to genuinely join
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  Speaker 2: them in problem solving around that issue opens the door
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  Speaker 2: for all the other things that we care about over time.
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  Speaker 2: But if you get that wrong, you often don't get
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  Speaker 2: a second chance to have a relationship. And so we
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  Speaker 2: really focus on meeting their needs and solving their problems.
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  Speaker 2: And then we continue to layer on all the other
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  Speaker 2: things that we know we need in pursuit of a
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  Speaker 2: mutual goal, which is health and well-being and more time
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  Speaker 2: at home with our families and their loved ones.
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  Speaker 1: So when you initially connect with these patients and you
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  Speaker 1: get this, I imagine, somewhat laundry list of issues, how
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  Speaker 1: do you decide what to triage first? Do you have
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  Speaker 1: a standard playbook or do you look at, I guess,
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  Speaker 1: maybe what's the most... glaring, obvious issue that they're facing
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  Speaker 1: that day?
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  Speaker 2: Yeah, it's typically the latter. We try to start with
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  Speaker 2: the thing that is the most glaring, obvious thing, because
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  Speaker 2: as I said, you know, folks will, they know what's
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  Speaker 2: important to them. So if you ask somebody, if you
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  Speaker 2: can't get past this, you're never going to get to
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  Speaker 2: the next step. Underneath that, we have really sophisticated AI-driven
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  Speaker 2: tools to help us determine what the right next best
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  Speaker 2: action is for each person. against our goals of achieving
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  Speaker 2: better health outcomes and reducing time in the hospital and
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  Speaker 2: improving the time that they can spend at home in
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  Speaker 2: the community. So we know what that list is and
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  Speaker 2: we know it in a way that is much more
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  Speaker 2: nuanced than most traditional healthcare systems do because we have
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  Speaker 2: so much more data. And we have so much more
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  Speaker 2: experience in seeing how this stuff plays out for someone.
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  Speaker 2: The thing about medicine often is that we create these
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  Speaker 2: very perfect circumstances in which we run experiments, right? So
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  Speaker 2: if I had a patient who only had a high
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  Speaker 2: blood pressure, I know exactly what medicine to use for them,
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  Speaker 2: depending on their comorbidities, their background, et cetera. But if
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  Speaker 2: I've got somebody who is sleeping on a park bench,
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  Speaker 2: struggling with substance use disorder, struggling with high blood pressure
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  Speaker 2: and diabetes, and fill in the blank, just gotten hospitalized
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  Speaker 2: for cellulitis. Like, I actually don't know. The data can't
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  Speaker 2: really tell me that, right? What we do have is historical,
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  Speaker 2: like real world data that we've then trained AI models
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  Speaker 2: on to help us exactly identify what the right next
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  Speaker 2: best action is for this person, including it might be,
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  Speaker 2: it's not a prescription. It's not a medication at all.
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  Speaker 2: It's to get that person off the park bench and
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  Speaker 2: into a warm bed at night because that's when everything
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  Speaker 2: else is possible. And so we really use that data
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  Speaker 2: to help inform what we're working on with the members.
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  Speaker 2: But we start with anchoring on what matters to them.
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  Speaker 2: Because if we can't do that, you lose the pipe,
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  Speaker 2: which is the relationship through which all of the bidirectional
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  Speaker 2: collaboration flows in order to drive better outcomes.
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  Speaker 1: Maybe thinking about the data piece of it a bit more,
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  Speaker 1: is that your data or the plan partner's data or
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  Speaker 1: some combination thereof?
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  Speaker 2: All of the above. Yeah, all of the above. We're
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  Speaker 2: like sponges for data. And so we take the sort
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  Speaker 2: of claims data. So, you know, what health care has
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  Speaker 2: been purchased on behalf of this person historically. We take
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  Speaker 2: the electronic medical record data. We take real time data
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  Speaker 2: on pharmacy fills and lab draws. We take all of
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  Speaker 2: the data that we generate through our conversations with folks.
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  Speaker 2: including like the conversational data itself, actually taking that and
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  Speaker 2: turning it into structured data. We take their real-time touch
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  Speaker 2: points with the health system, so their hospitalizations, their discharges.
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  Speaker 2: We will consume all of it and make sense of
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  Speaker 2: it and use it to drive the next best action
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  Speaker 2: that informs the way that we engage people to help
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  Speaker 2: them get better.
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  Speaker 1: Or something around the social determinants of health or quality
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  Speaker 1: of life?
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  Speaker 2: Yeah, and I think, you know, we in healthcare have
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  Speaker 2: done a good job of sort of fragmenting people. You know,
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  Speaker 2: we think of physical health as separate from behavioral health,
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  Speaker 2: as separate from social well-being. It's all one and the same, right?
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  Speaker 2: They all inform each other. And so we really try
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  Speaker 2: to holistically look at what matters to people and what
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  Speaker 2: is going to drive their outcomes and address the holistic
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  Speaker 2: needs of within the context of a real anchored relationship
• 16:35
  Speaker 2: with our care teams.
• 16:36
  Speaker 1: Thinking about AI as well, every discussion we've had on
• 16:40
  Speaker 1: this podcast the last two years has centered around AI
• 16:43
  Speaker 1: to some certain extent. How are you using AI maybe
• 16:46
  Speaker 1: differently now than you were a year or two ago?
• 16:48
  Speaker 2: Oh my goodness. Yeah, I think we started a year
• 16:52
  Speaker 2: or two ago, like everyone did, saying, okay, there's got
• 16:55
  Speaker 2: to be opportunities to be more efficient. We've got this
• 16:58
  Speaker 2: complex high-touch care model that relies on people to go
• 17:03
  Speaker 2: into the world and engage with other people and document
• 17:08
  Speaker 2: carefully what they do and try to select the right
• 17:11
  Speaker 2: tool from the toolkit. And so you can imagine all
• 17:13
  Speaker 2: of the administrative ways in which technology like AI could
• 17:16
  Speaker 2: make us more efficient, right? And in this case, the
• 17:20
  Speaker 2: sort of the North Star for us was always about
• 17:22
  Speaker 2: how do we free up our folks to spend more
• 17:24
  Speaker 2: time meaningfully in relationship with our members driving better health outcomes.
• 17:28
  Speaker 2: That It goes for our clinicians as much as our non-clinicians.
• 17:31
  Speaker 2: But how do I make sure that every moment spent
• 17:33
  Speaker 2: in the day to the best of our ability is
• 17:35
  Speaker 2: spent in high value things that only humans can do?
• 17:38
  Speaker 2: And how do I reduce the friction of all the
• 17:40
  Speaker 2: other things around that? So think like ambient listening during conversations,
• 17:45
  Speaker 2: scribing to enhance documentation, decision support, like I described to you,
• 17:50
  Speaker 2: that process of running through your brain to think, what
• 17:52
  Speaker 2: is the right next best thing to do for this person?
• 17:55
  Speaker 2: And the consequences of picking the wrong tool not making
• 17:59
  Speaker 2: the referral to the therapist when they needed it, not
• 18:02
  Speaker 2: making the referral to the food pantry, making the referral,
• 18:04
  Speaker 2: but having it not follow through because no one closed
• 18:06
  Speaker 2: the loop. These are all things that we can powerfully
• 18:10
  Speaker 2: automate and enhance with technology. And so we started there.
• 18:13
  Speaker 2: I think the thing that's been most interesting for me
• 18:16
  Speaker 2: of late, and so the ways in which we're using
• 18:18
  Speaker 2: AI today that we were different from before, is that
• 18:21
  Speaker 2: there historically has been, I think, a perception that folks
• 18:28
  Speaker 2: on Medicaid in particular and seniors would be less able
• 18:32
  Speaker 2: or willing to engage with technology. And we just find
• 18:36
  Speaker 2: that not to be true. So we've been focusing on
• 18:39
  Speaker 2: putting tools directly in the hands of our members. And
• 18:43
  Speaker 2: what we're finding is that it's not about the technology itself.
• 18:46
  Speaker 2: It's about the form factor, the user interface. So if
• 18:50
  Speaker 2: you're asking somebody's 92-year-old great-grandmother to you know, log on
• 18:56
  Speaker 2: to her phone law and then open an app and
• 18:59
  Speaker 2: then log on to a portal and two factor authenticate
• 19:01
  Speaker 2: her way into it and then click on the thing
• 19:04
  Speaker 2: to have a chat with it. That might be challenging.
• 19:07
  Speaker 2: That's probably not going to have super high uptake. But
• 19:11
  Speaker 2: if you are saying pick up the phone and make
• 19:13
  Speaker 2: a phone call and on the other side of this
• 19:15
  Speaker 2: phone call is going to be a voice agent. It's
• 19:17
  Speaker 2: actually going to sound a lot like a human. And
• 19:19
  Speaker 2: if you don't like it, you don't have to talk
• 19:21
  Speaker 2: to them. But if you do, here's a host of
• 19:24
  Speaker 2: things they can do on your behalf. Here's a host
• 19:26
  Speaker 2: of answers they can get access to because they're tapped
• 19:29
  Speaker 2: into your data. Folks are into it. Same goes for
• 19:33
  Speaker 2: SMS-based interactions. And so we're finding actually tons of really
• 19:38
  Speaker 2: interesting opportunities to directly impact our members using technology to
• 19:41
  Speaker 2: give them the tools to go reach the technology themselves,
• 19:46
  Speaker 2: which I think is wildly exciting. And I think it
• 19:48
  Speaker 2: has promise for... certainly our business, but the implications beyond
• 19:55
  Speaker 2: our business, just for what healthcare looks like for everyone,
• 19:59
  Speaker 2: it just gets me so buzzed. I just think like,
• 20:01
  Speaker 2: oh my gosh, we might finally, we've been stuck in
• 20:03
  Speaker 2: this like healthcare costs too much money and it's a
• 20:06
  Speaker 2: scarce resource and we've got a shortage of providers. What
• 20:11
  Speaker 2: are we going to do? And now I really believe
• 20:14
  Speaker 2: that these tools can actually upend that whole sense of
• 20:18
  Speaker 2: scarcity and start to make the resources much more abundant
• 20:24
  Speaker 2: and make access to people when we really need to
• 20:26
  Speaker 2: be with people that much more meaningful and that much
• 20:29
  Speaker 2: more available. And so that's really exciting for us.
• 20:32
  Speaker 1: Well, I would normally segue to a question about the
• 20:34
  Speaker 1: future at the end of this conversation, but it just
• 20:36
  Speaker 1: begs the question of You know, if you think about
• 20:39
  Speaker 1: care delivery, you know, five years from now, what do
• 20:41
  Speaker 1: you think is going to look drastically different compared to
• 20:44
  Speaker 1: what we're doing today?
• 20:45
  Speaker 2: This question is so interesting because like the crystal ball.
• 20:48
  Speaker 1: I mean, five years might even be too far away.
• 20:50
  Speaker 1: Maybe it might even be two to three years.
• 20:52
  Speaker 2: This is the thing that I go back and forth
• 20:55
  Speaker 2: on a daily basis about where I'm going to net
• 20:57
  Speaker 2: out here because none of this is inevitable, feels inevitable
• 21:01
  Speaker 2: to me. What does feel inevitable is that the technology
• 21:03
  Speaker 2: is going to improve dramatically. And today we already see
• 21:07
  Speaker 2: that AI tools perform as well as, if not better,
• 21:10
  Speaker 2: than your average clinician and most, if not all, clinical
• 21:13
  Speaker 2: reasoning tasks when given the same amount of information. Like,
• 21:17
  Speaker 2: oh my God, right? But that is true. It's only
• 21:19
  Speaker 2: going to get better. Today we have demonstrated in some
• 21:23
  Speaker 2: pockets that voice AI agents in the clinical setting are
• 21:31
  Speaker 2: as empathetic, as patient, and as able to engender trust clinicians.
• 21:36
  Speaker 2: Some settings, not entirely. It's only going to get better.
• 21:38
  Speaker 2: That is inevitable. What feels less clear to me is
• 21:42
  Speaker 2: the ways that we as agents within the healthcare system,
• 21:45
  Speaker 2: today with power, before, I don't know, maybe the bots
• 21:48
  Speaker 2: will take over someday, but until that day happens, we
• 21:51
  Speaker 2: get to decide how we deploy these tools. What is
• 21:54
  Speaker 2: less clear to me is that if we collectively choose
• 21:58
  Speaker 2: to deploy these tools in ways that actually transform our
• 22:00
  Speaker 2: healthcare system. So one potential outcome, which is Probable, I
• 22:05
  Speaker 2: would say, and certainly would follow the path of historical
• 22:08
  Speaker 2: technology adoption in healthcare is that we use these tools
• 22:12
  Speaker 2: to do the same stuff we did yesterday, just like
• 22:16
  Speaker 2: maybe faster and in order to generate more profit. In
• 22:19
  Speaker 2: which case the healthcare system looks exactly the same, just
• 22:23
  Speaker 2: more costly, right? Revenue cycle management becomes more efficient. We're
• 22:27
  Speaker 2: able to bill and code more effectively. Health systems are
• 22:30
  Speaker 2: able to put the bill in front of the payer
• 22:33
  Speaker 2: more quickly and and more accurately. The payer is going
• 22:35
  Speaker 2: to use AI to block them more quickly and more accurately.
• 22:39
  Speaker 1: I think we're already there on all three of those things.
• 22:40
  Speaker 2: Totally. And we could spend the next three years doing this.
• 22:44
  Speaker 2: We literally could, right? We could burn hundreds of millions
• 22:48
  Speaker 2: of dollars doing the same thing. And what happens underneath
• 22:52
  Speaker 2: that is costs go up, access goes down, outcomes remain
• 22:57
  Speaker 2: way below what they should be for the amount of
• 22:59
  Speaker 2: money we spend in the healthcare system. That is... the
• 23:01
  Speaker 2: cynical part of me says that is a probable outcome.
• 23:05
  Speaker 2: It's not the one I hope for. I don't know
• 23:07
  Speaker 2: if it's the more likely one depends on what day
• 23:09
  Speaker 2: of the week it is and who I've been talking to.
• 23:12
  Speaker 2: And then there's another path that we get to choose.
• 23:14
  Speaker 2: We get to choose that collectively, which is the path
• 23:16
  Speaker 2: that we're building for, which says that we use these
• 23:19
  Speaker 2: tools to actually do all the things I described earlier
• 23:21
  Speaker 2: to improve access quality and outcomes. And so what does
• 23:23
  Speaker 2: that look like? It looks like Every person having access
• 23:27
  Speaker 2: to a virtual agent that has access to their full
• 23:31
  Speaker 2: historical record, has the ability to help them cognitively reason
• 23:35
  Speaker 2: through what the right and expressed action is, can inform, empower,
• 23:39
  Speaker 2: and educate the patient directly, can connect to their care team,
• 23:44
  Speaker 2: can get them a warm handoff to a clinician where necessary,
• 23:48
  Speaker 2: that completely unbundles all of the stuff we've been trying
• 23:51
  Speaker 2: to jam into a 10-minute doctor's office visit, ineffectively, mind you.
• 23:55
  Speaker 2: And allows us to gather data over time about what
• 23:58
  Speaker 2: really matters to a person. Allows us to intervene regularly, frequently,
• 24:03
  Speaker 2: and with much higher fidelity to what actually is going
• 24:06
  Speaker 2: to matter. So, you know, today you go see your doctor.
• 24:09
  Speaker 2: You bring them your last three blood pressure readings if
• 24:11
  Speaker 2: you're lucky. Maybe you're super lucky and you have like
• 24:14
  Speaker 2: a device at home where they're uploading the data. Maybe
• 24:17
  Speaker 2: they look at it. Maybe they don't. Maybe it doesn't
• 24:18
  Speaker 2: talk to your EMR. They make a tweak. You go away.
• 24:21
  Speaker 2: You make another appointment. You come back three weeks from
• 24:24
  Speaker 2: now or six weeks from now or a month from now,
• 24:25
  Speaker 2: if you can remember. That doesn't have to happen anymore.
• 24:29
  Speaker 2: We could send you a note virtually, a text message,
• 24:32
  Speaker 2: a phone call. Hey, double the med. The script has
• 24:35
  Speaker 2: already been sent. Somebody, couriers on their way home. We'll
• 24:39
  Speaker 2: just track your blood pressures. If you have a question,
• 24:42
  Speaker 2: call day or night, middle of the night, whatever. Talk
• 24:44
  Speaker 2: to somebody. They will counsel you and coach you. If
• 24:47
  Speaker 2: there's an issue that needs to be triaged, we'll triage it. Suddenly,
• 24:50
  Speaker 2: the sense of scarcity, the sense that from a patient's perspective,
• 24:54
  Speaker 2: you've got to wait to see your doctor and, damn it,
• 24:57
  Speaker 2: you've got to get everything in in those 10 minutes.
• 24:59
  Speaker 2: That whole notion goes away. And the notion that you
• 25:02
  Speaker 2: have to rely on this one human who is fallible,
• 25:05
  Speaker 2: remembering everything about your context, parsing it all, meshing it
• 25:10
  Speaker 2: with the new information you're giving them, coming up with
• 25:12
  Speaker 2: the right hypothesis for what's going on, sifting through all
• 25:15
  Speaker 2: of the most recent medical literature and data to come
• 25:18
  Speaker 2: up with this idea, explaining it to you, and then
• 25:21
  Speaker 2: enacting it. Like all of that, it's obvious to me
• 25:24
  Speaker 2: that technology is far better at that than humans would be.
• 25:27
  Speaker 2: And so there is this huge opportunity to say to
• 25:30
  Speaker 2: every patient across the country, every person, you have access real-time, 24-7,
• 25:37
  Speaker 2: call it a clinical coach because I'm, my colleagues in
• 25:39
  Speaker 2: medicine are going to feel real attached about what is
• 25:41
  Speaker 2: a doctor, you know, and all of this. I don't know.
• 25:43
  Speaker 2: We'll have that conversation another day. But call it a
• 25:47
  Speaker 2: clinical coach or a care manager or an agent that
• 25:50
  Speaker 2: acts on your behalf to connect you to the right
• 25:52
  Speaker 2: care that you need. And that care is not rationed.
• 25:55
  Speaker 2: That care is available to you. That care is tailored
• 25:57
  Speaker 2: to you. It's precise and it's affordable. Like, That's a
• 26:02
  Speaker 2: world we could find ourselves in in three to five years.
• 26:05
  Speaker 2: A lot of things have to happen. And we have
• 26:07
  Speaker 2: to make some really intentional choices. And we have to
• 26:10
  Speaker 2: empower organizations like ours, I think, that are incentivized to
• 26:14
  Speaker 2: actually build towards this future. But I think we can
• 26:18
  Speaker 2: get there.
• 26:19
  Speaker 1: A couple of things that you mentioned struck me. You know,
• 26:21
  Speaker 1: you just mentioned incentives and organizations. And what I was
• 26:25
  Speaker 1: thinking about is, you know, where you sit, Citibox sits
• 26:28
  Speaker 1: in the ecosystem. Can you talk a little bit about
• 26:31
  Speaker 1: the market and why maybe the incumbents weren't doing what
• 26:33
  Speaker 1: you're doing previously? You know, and the complexity there, I think,
• 26:37
  Speaker 1: is probably the answer for why not. But I'd love
• 26:39
  Speaker 1: to hear your take on why your plan partners weren't
• 26:42
  Speaker 1: tackling this in the same way that you've been doing it.
• 26:45
  Speaker 2: Yeah, I think, you know, there are two sort of
• 26:48
  Speaker 2: key incumbent entities that drive how health care is experienced.
• 26:54
  Speaker 2: There are payers. that act as sort of financial intermediaries,
• 26:59
  Speaker 2: if you will, between the ultimate payer, either the employer
• 27:02
  Speaker 2: or the federal government or the state government. And they
• 27:06
  Speaker 2: are transactional organizations that are, they're insurance entities. And insurance
• 27:17
  Speaker 2: typically for healthcare and frankly, other things, doesn't actually focus
• 27:22
  Speaker 2: on changing behaviors per se. Their major lever is underwriting
• 27:26
  Speaker 2: behaviors and paying for them and managing benefits accordingly. That's
• 27:32
  Speaker 2: what insurers are built to do. And I would argue
• 27:33
  Speaker 2: they do that quite well, right? They're large because you
• 27:37
  Speaker 2: need scale. You need a ton of actuarial horsepower to
• 27:44
  Speaker 2: And then you underwrite and re-underwrite on an annual basis.
• 27:47
  Speaker 2: And you manage costs to the best of your ability
• 27:50
  Speaker 2: underneath that. These are not care delivery entities. And actually,
• 27:53
  Speaker 2: I would argue that the relationship between most people and
• 27:57
  Speaker 2: their insurance company precludes that type of a relationship. Because
• 28:03
  Speaker 2: when your insurance company is accountable for managing actually how
• 28:08
  Speaker 2: health care gets spent on your behalf... It's hard sometimes
• 28:11
  Speaker 2: to expect people to also trust that entity with, I
• 28:15
  Speaker 2: have needs that are coming up. Something has changed in
• 28:18
  Speaker 2: my life. I just lost my job. I got evicted.
• 28:23
  Speaker 2: I have this new pain and I'm not sure if
• 28:26
  Speaker 2: it's a new diagnosis. Is that going to change my premium?
• 28:28
  Speaker 2: I don't know, right? There's all these reasons why the
• 28:32
  Speaker 2: same entity that writes a letter to you that says
• 28:34
  Speaker 2: this benefit is not covered or... This doctor who you
• 28:37
  Speaker 2: used to see is no longer in your network might
• 28:39
  Speaker 2: not be the place you want to go to get
• 28:41
  Speaker 2: health care. Agreed. And it's worked in certain pockets, right?
• 28:44
  Speaker 2: Like we've seen the Kaiser model, which is incredible. And
• 28:47
  Speaker 2: there's some exceptions to that. But by and large, it's
• 28:51
  Speaker 2: really tricky. And I think it's I think it is
• 28:53
  Speaker 2: fair to say and also probably unfair to demand too
• 28:56
  Speaker 2: much from entities that were built to serve a different purpose. Now, providers...
• 29:02
  Speaker 2: This is your doctor, your trusted doctor, the nurse at
• 29:04
  Speaker 2: the doctor's office, the medical assistant who's been checking you
• 29:09
  Speaker 2: in and checking your blood pressure for the last 10
• 29:10
  Speaker 2: years whenever you go get your physical. These are highly
• 29:14
  Speaker 2: trusted organizations in the community that provide care, life-saving care.
• 29:21
  Speaker 2: You'd think they'd be perfect, right? But the business model
• 29:23
  Speaker 2: is wrong. The business model is fee for service, and
• 29:26
  Speaker 2: these primarily providers operate under a model that doesn't actually
• 29:31
  Speaker 2: hold them accountable for outcomes. You see the doctor. They
• 29:35
  Speaker 2: evaluate you to the best of their ability. They write
• 29:38
  Speaker 2: you a prescription. They get paid. If you fill the script,
• 29:41
  Speaker 2: doesn't matter. If you go straight from the doctor's office
• 29:44
  Speaker 2: to the emergency room for the same complaint, doesn't matter.
• 29:47
  Speaker 2: If you take the med, get side effects, try to
• 29:50
  Speaker 2: get help, doesn't work, you find yourself back in the hospital,
• 29:53
  Speaker 2: they still got paid. So So when we talk about,
• 29:57
  Speaker 2: you know, who ought to be doing this work, my
• 30:00
  Speaker 2: belief is that it is an entity that understands how
• 30:04
  Speaker 2: the dollars flow and is accountable for trying to change
• 30:08
  Speaker 2: outcomes that meaningfully move the needle, but also has the
• 30:12
  Speaker 2: capability to be in the community, be trusted, be proximate
• 30:16
  Speaker 2: to patients, deliver care, offer them comfort and sustenance and
• 30:22
  Speaker 2: advice and and be in their court and like really,
• 30:26
  Speaker 2: you know, and also do so with a view to
• 30:29
  Speaker 2: what's the long-term implication of the action I've just taken,
• 30:32
  Speaker 2: not how do I get paid today for all the
• 30:35
  Speaker 2: visits I did.
• 30:36
  Speaker 1: So maybe teasing that out a little bit more, you know,
• 30:38
  Speaker 1: from a business model perspective, we're sitting in the four
• 30:40
  Speaker 1: walls of Bloomberg, so I have to talk a little
• 30:42
  Speaker 1: bit about business. How does your business model work? How
• 30:45
  Speaker 1: do you get paid from your partners?
• 30:46
  Speaker 2: Yeah. So we enter into contracts that align our work
• 30:50
  Speaker 2: to outcomes, as I said. And we think about a
• 30:53
  Speaker 2: number of outcomes. We think about balancing quality, engagement, the
• 30:57
  Speaker 2: member experience, and cost. And we take a population of
• 31:01
  Speaker 2: folks who are complex in their needs and hard to reach,
• 31:05
  Speaker 2: whose costs would otherwise be escalating and typically are disproportionate
• 31:11
  Speaker 2: to what we would expect for the comorbidities that they have,
• 31:14
  Speaker 2: where there's opportunity for us to really help them, and who,
• 31:18
  Speaker 2: as a result, are also spending more time in the
• 31:20
  Speaker 2: hospital than they should achieving worse outcomes on quality measures
• 31:23
  Speaker 2: like diabetes control and blood pressure control and medication adherence
• 31:28
  Speaker 2: and follow-ups post-psychiatric hospitalizations, all these key quality measures that
• 31:32
  Speaker 2: we know are tied to quality of life and morbidity
• 31:34
  Speaker 2: as well as cost. And we say to the health
• 31:36
  Speaker 2: plan partner, give us accountability for caring for this population.
• 31:41
  Speaker 2: Here are the things we will do. We will find them,
• 31:43
  Speaker 2: we will engage them, we will provide care to them,
• 31:45
  Speaker 2: and we will do so with an eye to overall
• 31:48
  Speaker 2: reducing medical costs relative to what they would have been
• 31:52
  Speaker 2: while improving quality and improving engagement and improving the member experience.
• 31:57
  Speaker 2: And if we do all of those things, we actually
• 31:59
  Speaker 2: generate savings for the healthcare system. And we get to
• 32:02
  Speaker 2: keep some of those savings as our margin. So our
• 32:05
  Speaker 2: business model says, I could do 50 visits a day.
• 32:08
  Speaker 2: I could do three. I could spend six hours with
• 32:12
  Speaker 2: a frail elderly person in their home who needs... a
• 32:16
  Speaker 2: multidisciplinary visit from a doctor, a psychiatrist, a nurse practitioner,
• 32:21
  Speaker 2: a care manager, to just coordinate all of their services,
• 32:25
  Speaker 2: make sure they've got food, make sure they've got their
• 32:27
  Speaker 2: meds right, make sure that the wound on their leg
• 32:29
  Speaker 2: is cared for. We do all those things. I'm not
• 32:31
  Speaker 2: going to bill for all of those visits. I'm going
• 32:33
  Speaker 2: to wait until that delivers a return on investment when
• 32:37
  Speaker 2: she is not in the hospital because we prevented the hospitalization,
• 32:40
  Speaker 2: we prevented the fall, we prevented the polypharmacy, confusion, and
• 32:46
  Speaker 2: overdose on one med versus the other. We kept her
• 32:49
  Speaker 2: in the home, in the community, and we improved her
• 32:51
  Speaker 2: quality outcomes. We get paid when we reconcile against that
• 32:55
  Speaker 2: in the long term. That means we're incentivized to spend
• 32:57
  Speaker 2: the time necessary to get the outcomes that we're looking for.
• 33:01
  Speaker 2: We're also incentivized to do things that the healthcare system
• 33:03
  Speaker 2: doesn't typically get reimbursed for. That home visit, that social
• 33:07
  Speaker 2: worker who's making phone calls to food pantries to make
• 33:10
  Speaker 2: sure we can get the food in the home. Those
• 33:12
  Speaker 2: types of things are not reimbursed very well, if at all,
• 33:16
  Speaker 2: in most healthcare systems. But often they can be the
• 33:18
  Speaker 2: difference between somebody staying at home versus having to go
• 33:21
  Speaker 2: to the hospital.
• 33:22
  Speaker 1: You mentioned quality a number of times. How do you
• 33:24
  Speaker 1: guys think about it and measure it? And it's one
• 33:26
  Speaker 1: of the subjects that I'm fascinated in my discussion with
• 33:28
  Speaker 1: leaders in healthcare, how they think about quality.
• 33:30
  Speaker 2: Yeah. Yeah. I mean, we, as an ecosystem, have an opportunity,
• 33:36
  Speaker 2: I think, to streamline quality measures. There are a lot
• 33:39
  Speaker 2: of quality metrics. And Medicaid incentivizes quality as does Medicare
• 33:45
  Speaker 2: through STARS. Some of those are process measures, candidly, that
• 33:49
  Speaker 2: don't actually translate to outcomes that are important today, but
• 33:53
  Speaker 2: I understand why they were put in place. There is,
• 33:57
  Speaker 2: I think, a real shared belief that we have an
• 34:00
  Speaker 2: opportunity to streamline these quality measures, but we think about
• 34:04
  Speaker 2: clinical quality metrics. So if you have diabetes, I know
• 34:09
  Speaker 2: that if your hemoglobin A1c, that's a measure of how
• 34:12
  Speaker 2: much sugar there is in your blood, is above eight,
• 34:16
  Speaker 2: that your risk of a heart attack, a stroke, infection,
• 34:22
  Speaker 2: amputation is meaningfully higher than if it was below. So
• 34:26
  Speaker 2: like a good measure of whether you're getting good quality
• 34:29
  Speaker 2: health care is we know you have diabetes. We're taking
• 34:32
  Speaker 2: care of it. And the meds are out there to
• 34:34
  Speaker 2: do that. It requires interventions, lifestyle, as well as pharmacologic.
• 34:39
  Speaker 2: But with the right care, we can get everybody with
• 34:42
  Speaker 2: diabetes under good control. Right. So we should incentivize that.
• 34:47
  Speaker 2: Similar with blood pressure. I know if your blood pressure
• 34:49
  Speaker 2: is over 140, over 90, that your risk factors for
• 34:52
  Speaker 2: all kinds of bad things go up. And that if
• 34:55
  Speaker 2: we can keep it below, it's a good sign that
• 34:58
  Speaker 2: somebody is paying attention and somebody is taking good care
• 35:01
  Speaker 2: of you. And so those are things like that, that
• 35:03
  Speaker 2: we that we measure and incentivize within our contracts and
• 35:07
  Speaker 2: that we take real pride in being able to move
• 35:09
  Speaker 2: the needle on.
• 35:09
  Speaker 1: In terms of those chronic conditions, do you do all
• 35:12
  Speaker 1: the work yourself or do you partner with some of
• 35:13
  Speaker 1: the other organizations that are focused in those areas?
• 35:16
  Speaker 2: We partner. We certainly partner. I think the examples I
• 35:20
  Speaker 2: gave you, diabetes, high blood pressure, I've talked a lot
• 35:22
  Speaker 2: about sort of anxiety, depression, and what I would consider
• 35:25
  Speaker 2: primary behavioral health. Those are things I believe that primary
• 35:27
  Speaker 2: care should do. And by and large, we take care
• 35:30
  Speaker 2: of those types of conditions ourselves. There are so many
• 35:33
  Speaker 2: others that are outliers. There are folks who have complexity
• 35:36
  Speaker 2: around the chronicity of their diseases, the way they interact
• 35:39
  Speaker 2: with each other. So we certainly partner with specialists. We
• 35:42
  Speaker 2: partner with other value-based care providers who focus on specific
• 35:46
  Speaker 2: conditions to make sure that we're bringing the right care
• 35:50
  Speaker 2: to our members. And I have no, there's no hubris
• 35:53
  Speaker 2: about this. I think part of the role of an
• 35:55
  Speaker 2: organization like ours is to coordinate the healthcare system more
• 35:58
  Speaker 2: effectively in service of members and And so we really
• 36:02
  Speaker 2: think we take that role pretty seriously about coordinating and
• 36:04
  Speaker 2: collaborating with others as well.
• 36:06
  Speaker 1: Can you talk a little bit about, you just mentioned members,
• 36:08
  Speaker 1: the size of the organization today, you know, which markets
• 36:11
  Speaker 1: you're in and maybe what your growth trajectory has been
• 36:13
  Speaker 1: since your founding?
• 36:14
  Speaker 2: Yeah. So we serve 11 states and each state we're in,
• 36:18
  Speaker 2: we're typically ideally statewide or in multiple geographic regions. We
• 36:22
  Speaker 2: started in sort of more dense urban and now we're
• 36:25
  Speaker 2: serving rural populations as well. And so we really have
• 36:28
  Speaker 2: a lot of scope in the states that we're in.
• 36:29
  Speaker 2: I try to list them all. I could probably do it,
• 36:32
  Speaker 2: but it probably wouldn't be that helpful. But think sort
• 36:35
  Speaker 2: of like northeast all the way down to Florida and
• 36:38
  Speaker 2: then across the Midwest. We have not quite made it
• 36:40
  Speaker 2: out all the way up to the West Coast, but
• 36:42
  Speaker 2: we're on our way. We have plans afoot, yeah, for sure.
• 36:46
  Speaker 2: We serve about 200,000 members, but these folks represent the
• 36:50
  Speaker 2: highest need, highest cost of a population. And so from
• 36:54
  Speaker 2: a sort of overall company revenues perspective, the cost of
• 36:58
  Speaker 2: that care is meaningful and the opportunity to improve outcomes
• 37:03
  Speaker 2: while reducing cost remains pretty large there too.
• 37:05
  Speaker 1: Is there a big difference in terms of the needs?
• 37:07
  Speaker 1: I imagine there is, but between the urban patients and
• 37:10
  Speaker 1: the rural?
• 37:11
  Speaker 2: Yes and no. I mean, I think.
• 37:13
  Speaker 1: Yeah, I was going to say, what have you found
• 37:14
  Speaker 1: that maybe is different that's striking?
• 37:16
  Speaker 2: Yeah, I think probably not unobvious.
• 37:21
  Speaker 1: It's not surprising.
• 37:22
  Speaker 2: Yeah. But the big thing is that where we see
• 37:26
  Speaker 2: healthcare workforce and healthcare access challenges being most acute are
• 37:29
  Speaker 2: in rural areas.
• 37:30
  Speaker 1: The deserts that are there.
• 37:32
  Speaker 2: Just absolute primary care and specialty deserts. And so that's
• 37:37
  Speaker 2: been huge. I think the other thing that we see
• 37:40
  Speaker 2: is real heterogeneity in terms of the quality and capability
• 37:44
  Speaker 2: of the healthcare delivery system. And that includes subjective measures.
• 37:49
  Speaker 2: I mean, I think one of the things that is
• 37:50
  Speaker 2: interesting about healthcare is just from a market's perspective, is
• 37:55
  Speaker 2: there's a real asymmetry of information. As a consumer, as
• 37:58
  Speaker 2: a patient, it's very hard to know what a high-quality
• 38:01
  Speaker 2: provider is. Do you say that even as a doctor?
• 38:07
  Speaker 2: Less so. I have a lot more advantages, I would say.
• 38:10
  Speaker 2: But I think most sort of lay people find it
• 38:12
  Speaker 2: really hard to know, right? And when you think about
• 38:15
  Speaker 2: all the prerequisites for a functioning market, people should be
• 38:18
  Speaker 2: able to shop based on things that matter to them, right?
• 38:21
  Speaker 2: That's how a market works. The market drives differentiation and quality,
• 38:25
  Speaker 2: and people make decisions on the basis of that. People
• 38:28
  Speaker 2: find that very hard to discern. And so in rural
• 38:31
  Speaker 2: areas where there's a paucity of choice, people make decisions
• 38:37
  Speaker 2: about what is a good provider, right? often not based
• 38:41
  Speaker 2: on objective data because that data is obfuscated and not
• 38:44
  Speaker 2: available to them. And so that changes the landscape of
• 38:48
  Speaker 2: the market as well. People are driving a long period
• 38:50
  Speaker 2: of time to go to the hospital. They may drive
• 38:53
  Speaker 2: past their local health center and go to another institution
• 38:57
  Speaker 2: that is further away and more costly because of a
• 39:00
  Speaker 2: perceived difference in value that is created there. or in
• 39:04
  Speaker 2: the perceived difference in quality that's created there. And so
• 39:07
  Speaker 2: that has been a real issue and an opportunity, I think, for, again,
• 39:11
  Speaker 2: tech-enabled care, all the ways I described to you about
• 39:13
  Speaker 2: how technology might help us really blow open the clinical
• 39:19
  Speaker 2: operating model in a way that creates like real access
• 39:24
  Speaker 2: and abundance of access to health care and to clinical services.
• 39:28
  Speaker 2: That is just it couldn't be more true in rural
• 39:31
  Speaker 2: areas because of the constraints that folks are operating under today.
• 39:36
  Speaker 1: As I think about your rollout, I'm sure you have
• 39:39
  Speaker 1: a playbook now that you've done it a couple of times.
• 39:41
  Speaker 1: But I guess what is the biggest hurdle to entering
• 39:43
  Speaker 1: a new geography or a new state?
• 39:46
  Speaker 2: There's a couple. One is because our model doesn't have
• 39:49
  Speaker 2: us hanging up a shingle and billing fee for service,
• 39:53
  Speaker 2: we need a really good partner. And so we look
• 39:55
  Speaker 2: at health plan partners. We look at health system partners.
• 39:58
  Speaker 2: We enter new markets with an anchor partner. And making
• 40:02
  Speaker 2: sure that we take the time up front to align
• 40:04
  Speaker 2: our incentives is critical. And it just takes time. You know,
• 40:08
  Speaker 2: if we were a traditional bricks and mortar primary care practice,
• 40:11
  Speaker 2: we would enter a market and say, pay us network rates.
• 40:16
  Speaker 2: You agree to pay us X dollars for every visit
• 40:19
  Speaker 2: we do that meets this complexity. Great. We're good to go.
• 40:22
  Speaker 2: You can get those contracts done very quickly. It's a
• 40:24
  Speaker 2: standard template. It's a fee for service construct. Our model says, no,
• 40:29
  Speaker 2: we'd like to understand who needs us the most in
• 40:32
  Speaker 2: the population, not just in abstract, but like on a very,
• 40:36
  Speaker 2: very specific detailed basis. We need to understand what their
• 40:39
  Speaker 2: costs of care and their outcomes would have been absent us.
• 40:43
  Speaker 2: We need to agree on that. And then we need
• 40:45
  Speaker 2: to agree on a set of targets to improve all
• 40:47
  Speaker 2: of those metrics over time. And we're going to contract
• 40:49
  Speaker 2: around that. And we're going to contract around exceptions and
• 40:52
  Speaker 2: things that could change that might reformulate our starting hypotheses
• 40:56
  Speaker 2: and that will govern our partnership over time. It takes time.
• 40:59
  Speaker 2: And that is the longest poll for us. But we
• 41:01
  Speaker 2: think that that is the most important step, right? Like
• 41:04
  Speaker 2: if you share, if you align incentives, then I know
• 41:08
  Speaker 2: that if I have a successful year, my partners are
• 41:10
  Speaker 2: going to have a successful year. You know, the interesting
• 41:11
  Speaker 2: thing about the way that most health systems and payers work,
• 41:16
  Speaker 2: when the health systems are having a good year, the
• 41:17
  Speaker 2: payers are having a terrible year. And they're trying to
• 41:20
  Speaker 2: claw that back and vice versa, right? That cannot be
• 41:24
  Speaker 2: the way that we have to operate as a healthcare system.
• 41:26
  Speaker 2: We've got to be rowing in the same direction on
• 41:28
  Speaker 2: the same page. And so we really spend the time
• 41:31
  Speaker 2: doing that. The other thing that takes time is getting
• 41:33
  Speaker 2: the right team in place, right? Mm-hmm. Getting them credentialed
• 41:36
  Speaker 2: and licensed. You beat me to that question. Yeah. Yeah.
• 41:38
  Speaker 1: There's a boots on the ground aspect that you need
• 41:40
  Speaker 1: to fund.
• 41:41
  Speaker 2: That's right. Yeah.
• 41:43
  Speaker 1: Thinking about funding, you just did a series E, I believe,
• 41:46
  Speaker 1: a couple months ago. And then you did your first acquisition.
• 41:48
  Speaker 2: That's right.
• 41:48
  Speaker 1: Can you talk about that acquisition? What went into it?
• 41:52
  Speaker 2: Yeah, absolutely. This is our first. And so we're learning
• 41:55
  Speaker 2: as we go. But really exciting. I think what we're
• 41:57
  Speaker 2: seeing is that we built a chassis as a business
• 42:01
  Speaker 2: now over nine years. That's really strong. It's anchored in technology,
• 42:07
  Speaker 2: which means it's much more scalable than a more rigid
• 42:10
  Speaker 2: model would be. We really understand our customer. And I
• 42:14
  Speaker 2: mean both the patient, the member, and the payer and
• 42:20
  Speaker 2: the providers that exist in that ecosystem where we've sort
• 42:23
  Speaker 2: of earned the right to be quite opinionated about what
• 42:25
  Speaker 2: people need in order to move outcomes because we can
• 42:28
  Speaker 2: deliver against it. We have done. And that gets me
• 42:31
  Speaker 2: excited about... the possibilities of scaling this business quite quickly.
• 42:35
  Speaker 2: We've been growing organically, really robustly. As I said earlier,
• 42:39
  Speaker 2: there's lots of demand for what we do. But we
• 42:43
  Speaker 2: see the opportunity to also be an aggregator for others,
• 42:46
  Speaker 2: to bring onto our platform businesses that have similar business models,
• 42:51
  Speaker 2: similar populations that they serve, but that don't have the
• 42:53
  Speaker 2: scale and don't have the technology that we do, and
• 42:56
  Speaker 2: use that to make us all better. ultimately we have
• 43:00
  Speaker 2: to solve this cost quality value conundrum that we're in.
• 43:06
  Speaker 2: I do think it is like existential. We just can't
• 43:10
  Speaker 2: as a system sustain the rate of growth of healthcare costs,
• 43:13
  Speaker 2: especially when it doesn't come with a commensurate improvement in outcomes.
• 43:16
  Speaker 2: We cannot do that. And so building a business that
• 43:20
  Speaker 2: is scale, that is efficient, that is able to leverage
• 43:25
  Speaker 2: all of the learnings that we've gained across a big
• 43:27
  Speaker 2: population of folks, I think is our part of doing
• 43:30
  Speaker 2: our part to solve this existential problem. And we take
• 43:33
  Speaker 2: it really seriously. And so we're excited to do that.
• 43:35
  Speaker 2: We're excited to scale by acquisition and we'll continue to
• 43:38
  Speaker 2: do more as we see opportunities arise.
• 43:40
  Speaker 1: I mean, maybe this is a loaded question, but is
• 43:43
  Speaker 1: your ultimate goal to be a national provider?
• 43:45
  Speaker 2: Absolutely. Okay. Yeah. Easy one to answer. I was like,
• 43:48
  Speaker 2: oh no, don't ask me a hard one. Yes.
• 43:52
  Speaker 1: You know, we've only got a couple minutes left, and
• 43:54
  Speaker 1: I like to ask people at the end of these
• 43:56
  Speaker 1: an element about, you know, their personal decision-making and something
• 44:00
  Speaker 1: that maybe drives them. And, Toyin, I was wondering if
• 44:02
  Speaker 1: there was a lesson from your personal or professional life
• 44:04
  Speaker 1: that you see as driving your mission or that you've
• 44:07
  Speaker 1: made your North Star.
• 44:09
  Speaker 2: Yeah. You know, I think a lot about how hard
• 44:15
  Speaker 2: and how important it is to build for folks who
• 44:18
  Speaker 2: don't typically have a seat at the table, especially... Now,
• 44:23
  Speaker 2: because these are folks who have the most to lose
• 44:25
  Speaker 2: and the most to gain by a system that either
• 44:28
  Speaker 2: works for them or doesn't. And for me, there's been
• 44:32
  Speaker 2: so many personal stories. I grew up in Africa and
• 44:35
  Speaker 2: Kenya at the height of the AIDS epidemic. And I
• 44:39
  Speaker 2: remember being a young person. watching a debate. I think
• 44:44
  Speaker 2: it was in the UN Security Council. I don't remember.
• 44:46
  Speaker 2: It was like this little TV. It was like kind
• 44:48
  Speaker 2: of grayed out. And there was a debate about how
• 44:52
  Speaker 2: we would fund, we globally would fund getting antiretroviral drug
• 44:57
  Speaker 2: treatment to developing countries. And at the time, I was
• 45:02
  Speaker 2: an early teen, maybe an adolescent, and I had seen
• 45:06
  Speaker 2: just so many people die Growing up in Africa, you know,
• 45:10
  Speaker 2: in the 80s and 90s, you know, one in five
• 45:13
  Speaker 2: adults had HIV AIDS. And it was just, it was everything.
• 45:17
  Speaker 2: It permeated everything about, you know, my sense of my mortality,
• 45:22
  Speaker 2: my sense of my possibilities, my sense of just life.
• 45:26
  Speaker 2: And I heard a debate during which someone said from
• 45:30
  Speaker 2: a developed country, a resourced country, what's the point? of
• 45:35
  Speaker 2: providing treatment to these people. Their lives are bad enough
• 45:38
  Speaker 2: as it is. They probably can't even tell time. We
• 45:41
  Speaker 2: can't afford it. Let's not bother. And, and I remember thinking,
• 45:45
  Speaker 2: oh my God, they're talking about me and people like
• 45:47
  Speaker 2: me and how can it possibly be so right. You know,
• 45:52
  Speaker 2: I also got to watch like American TV and I
• 45:56
  Speaker 2: could see the sort of like the excesses And I
• 46:00
  Speaker 2: could see this, like, this sort of belief that us
• 46:03
  Speaker 2: and them and we're not the same. And I saw that.
• 46:06
  Speaker 2: I've seen that every single place that I've operated. I
• 46:09
  Speaker 2: saw that, you know, training as a physician in Boston,
• 46:14
  Speaker 2: which is arguably the bastion of, like, medical technology globally.
• 46:17
  Speaker 2: I mean, you can't, you know, cross an intersection without
• 46:20
  Speaker 2: tripping over some, like, world-class scientist and researcher. Top of
• 46:25
  Speaker 2: the line everything. And... And yet, you know, when you're
• 46:29
  Speaker 2: in a clinic in South Boston taking care of people
• 46:31
  Speaker 2: on Medicaid, you feel the difference. You feel that sort
• 46:36
  Speaker 2: of like implicit step down between what is available to folks.
• 46:41
  Speaker 2: When I was making referrals to therapists for people with trauma, PTSD,
• 46:46
  Speaker 2: like real psychiatric needs, knowing full well they wouldn't get
• 46:50
  Speaker 2: seen for six weeks and that the person who saw
• 46:53
  Speaker 2: them may have 45 minutes to try to learn their
• 46:56
  Speaker 2: entire life story and their psychiatric history. And following that,
• 47:00
  Speaker 2: they may barely be able to see them for 10
• 47:02
  Speaker 2: minutes every six weeks to follow up. Like I saw
• 47:05
  Speaker 2: that and I felt it. And I think for me,
• 47:09
  Speaker 2: you know, the question about whether we can take technology
• 47:13
  Speaker 2: and capital and resources and make nice things nicer for
• 47:18
  Speaker 2: rich people is not interesting, nor does it change the world.
• 47:22
  Speaker 2: The question about whether we can take technology and resources
• 47:26
  Speaker 2: and make things meaningfully better for those amongst us who
• 47:29
  Speaker 2: have the least, that's hard. And that's important. And that's
• 47:34
  Speaker 2: the kind of thing that changes democracies. It changes generations.
• 47:38
  Speaker 2: It changes empires. And that's the thing I want to
• 47:41
  Speaker 2: be part of. And so for me, it's always been about, like,
• 47:45
  Speaker 2: how do I make sure that the people who don't
• 47:47
  Speaker 2: have a seat at the table... who have the most
• 47:50
  Speaker 2: to lose and the most to gain from a system
• 47:52
  Speaker 2: that today fails them drastically every single day, can be
• 47:56
  Speaker 2: the beneficiaries, disproportionately the beneficiaries, of the incredible things that
• 48:01
  Speaker 2: our society has created, such that we can all sort
• 48:04
  Speaker 2: of elevate ourselves. That's interesting to me. And that's powerful
• 48:08
  Speaker 2: to me. And that is like, that's life's work worthy,
• 48:10
  Speaker 2: you know? So that's the thing for me.
• 48:14
  Speaker 1: Well, thank you so much for sharing that and for
• 48:16
  Speaker 1: the lesson on CityBlock Health. It's been super educational, and
• 48:19
  Speaker 1: I love your energy and excitement, and I can't wait
• 48:21
  Speaker 1: to see what you guys do next.
• 48:23
  Speaker 2: Thank you so much. That's Dr.
• 48:25
  Speaker 1: Toyin Ajahi, CEO of CityBlock Health. Thank you for listening
• 48:29
  Speaker 1: to this episode of the Vanguards of Healthcare podcast. And
• 48:33
  Speaker 1: don't forget to click the follow button on your favorite
• 48:34
  Speaker 1: podcast app or website so you never miss an interview
• 48:37
  Speaker 1: with the leaders rewriting the playbook on healthcare innovation. Until
• 48:40
  Speaker 1: next time, take care.
• 49:13
  Speaker 2: Thank you.